Hybrid Surgery for Intralobar Pulmonary Sequestration With Aortic Aneurysm

Aneurysmal artery supplying pulmonary sequestration: successful combined approach

A 62-year-old man was diagnosed with an asymptomatic intralobar pulmonary sequestration supplied by a short-neck proximal 57×25 mm aneurysmal artery originating from the mid-descending aorta. The patient underwent thoracic endovascular aneurysm repair; an aortic endograft was released to entirely restore the aberrant vessel. Then, pulmonary resection was performed. A triportal video-assisted left lower lobectomy was carried out. The thoracic endovascular aneurysm repair minimized the risk of bleeding and allowed a safe pulmonary resection with a minimally invasive approach.

Surgical strategy for pulmonary sequestration: Focus on precautions for aberrant vessels under minimally invasive surgery

Background

Recently, thoracoscopic resection of pulmonary sequestration has become more common, since resection of an aberrant artery using an end-stapler is a safe maneuver in many cases. However, injury of the vessels can lead to major hemorrhage. We reported our surgical experience based on thoracoscopic surgery, with five cases of interlobar pulmonary sequestration, focusing on precautions for aberrant arterial vessels.

Object and methods

We performed pulmonary resections for five patients with interlobar pulmonary sequestration in a lower lobe (left, n = 4; right, n = 1) between April 2004 and May 2020. All aberrant vessels were derived from the lower thoracic artery. Two patients had a single aberrant artery and three had multiple. In four patients, these vessels were detected before surgery, and pulmonary sequestration was diagnosed in four. In one elderly patient, the aberrant vessel was overlooked, and lung cancer was suspected before surgery. Angiography or multidetector-row computed tomography was subsequently performed in four cases. The surgical plan was determined according to the location and size of the pulmonary lesion and three-dimensional images of aberrant vessels.

Result

In all patients, approaches were made thoracoscopically. Hemorrhage from an anomalous vessel was encountered in one case. Pulmonary resections included two lobectomies and three limited resections. Angioplasty for the root of anomalous branches was performed following pulmonary resections under converted minimal lateral thoracotomy in two cases.

Conclusion

Preoperative assessment of the anatomical variations in abnormal vessels is essential to achieve safe surgical procedures. According to the situation of the aberrant vessels, selecting surgical procedures with consideration of potential subsequent complications arising over a long period of time is important.

Lessons learned from hybrid surgery with preoperative coil embolization for an aberrant artery in pulmonary sequestration

Background

The optimal management of an aberrant artery in pulmonary sequestration (PS) is controversial. Several studies have shown that hybrid surgery with preoperative coil embolization for an aberrant artery and surgical resection of the sequestrated lung is effective. However, there are no clear indications for the procedure.

Case presentation

A 68-year-old woman without any complaints was diagnosed with right intralobar PS, which was supplied by an aberrant artery from the thoracic aorta, via computed tomography performed during a medical examination. In addition, lung adenocarcinoma was detected over the border between the right upper and middle lobes. Preoperative coil embolization was performed by an interventional radiologist the day before surgery to decrease the risk of severe intraoperative hemorrhage. On the following day, bi-lobectomy of the right upper and middle lobes for lung adenocarcinoma with systemic lymph node dissection and segmentectomy of the sequestrated lung with thoracotomy was performed. Although no active hemorrhage was observed during surgery, the aberrant artery was challenging to dissect using an energy device due to the presence of an intravascular coil. Eventually, the coil stump was exposed, and it was cut with scissors. The postoperative course was uneventful.

Conclusions

We reported the pitfall of the hybrid surgery for intralobar PS. Preoperative coil embolization can prevent fatal intraoperative hemorrhage. If embolization is performed using a coil for an aberrant artery supplied from the thoracic aorta, where and how to dissect the aberrant artery should be cautiously determined based on preoperative images, with consideration of the presence of an intravascular coil.

Isolated endovascular repair of anomalous systemic arterial supply to the left basal lung

Anomalous systemic arterial supply to the left basal lung is a rare congenital lung malformation, and its optimal treatment strategy is not well defined. We present a case of a 61-year-old man who underwent thoracic endovascular aortic repair (TEVAR) for anomalous systemic arterial supply to the left basal lung complicated with aneurysmal dilatation of the aberrant feeding artery. Computed tomography angiography after TEVAR revealed significant shrinkage of the aneurysmal portion as well as complete occlusion of the aberrant feeding artery. TEVAR proved to be a safe and efficient treatment for this rare arterial abnormality.

An uncommon cause of massive haemothorax and treatment under cardiopulmonary bypass

Pulmonary sequestration is defined as nonfunctioning lung tissue that is not in normal continuity with the tracheobronchial tree and that has a systemic arterial blood supply. Herein, we aimed to present a case of a 34-year-old male patient who had massive left-sided haemothorax on admission due to a giant intralobar pulmonary sequestration. An emergent repair was performed under cardiopulmonary bypass with axillofemoral cannulation.

External Corset Technique in a Patient With Anomalous Artery Supply to the Left Basal Segment

Postoperative aneurysmal formation of the anomalous artery stump has been reported in the systemic arterial supply to the basal segment of the left lung, whereas the effective preventive strategy remains unclear. Herein we report a case successfully treated with a new external corset technique of an anomalous artery stump. A 54-year-old man with a history of repeated hemoptysis underwent a left lower lobectomy. The anomalous artery stump with a 1.1 cm diameter was wrapped using woven Dacron vascular graft. No aneurysmal change has been observed in the computed tomography obtained after 3 years of follow-up.

Intralobar pulmonary sequestration: incidental finding in an asymptomatic patient

We describe a case of a 58-year-old male who presented to the emergency room with symptoms related to an appendicitis. A computed tomography scan with contrast confirmed the diagnosis of acute appendicitis but also revealed a mass medially in the base of the inferior lobe of the right lung. The mass measured 6.7 cm AP × 3.7 cm transverse. It had multiple lobulations and the anterior aspect was of very low density, possibly representing accumulated mucoid material. The mass had an arterial connection from the descending thoracic aorta and a venous drainage into the right pulmonary vein, classical features of intralobar pulmonary sequestration. The physical exam was unremarkable, and the patient had no history of pulmonary symptoms. This case helps increase awareness of intralobar pulmonary sequestration, a rare condition that may be asymptomatic.

Treatment of an Aberrant Arterial Aneurysm with Intralobar Pulmonary Sequestration: A Case Report

An aberrant arterial aneurysm with pulmonary sequestration is rare. Here, we report about a 35-year-old man who had no symptoms related to pulmonary sequestration. Computed tomography revealed an aberrant arterial aneurysm with an 18 mm in diameter with intralobar pulmonary sequestration, which gradually increased in size to 27 mm over 5 years. The patient underwent thoracic endovascular aortic repair with coil embolization for the aneurysmal distal branches to prevent aneurysm rupture. The postoperative course was unremarkable without a need for lobectomy. During a 1-month follow-up period, the aneurysm shrunk with no endoleaks. Stent-graft placement and coil embolization represent an effective and less invasive treatment option to completely block systemic arterial flow and unexpected retrograde backflow and control the expansion of the aneurysm.

Hybrid and Endovascular Treatment of Pulmonary Sequestration: Two Case Reports and Literature Review

Pulmonary sequestration is an uncommon congenital pulmonary anomaly associated with aberrant systemic arteries which usually originate from the thoracic aorta or abdominal aorta. Traditionally, surgical resection and ligation of the feeding vessels are the gold standard treatments of the disease. Endovascular intervention and hybrid operation are promising treatment options. However, the case reports with endovascular and hybrid treatment are sparse to our knowledge. We presented 2 symptomatic adult patients with pulmonary sequestration successfully treated by hybrid operation and transcatheter embolization, respectively. Besides, we reviewed 37 previously reported cases of pulmonary sequestration treated by endovascular or hybrid treatment.

Thoracic endovascular aortic repair of an aberrant arterial aneurysm with pulmonary sequestration

We describe a treatment strategy for an aberrant arterial aneurysm associated with pulmonary sequestration. A 58-year-old man with impending aberrant arterial aneurysm rupture underwent a 2-stage surgery that included an emergency thoracic endovascular aortic repair (TEVAR) of the descending aorta to occlude the origin of the aberrant artery, followed by lobectomy. TEVAR can lead to faster occlusion of the aneurysm and can avoid operative risk of aneurysm rupture during lobectomy. The aberrant artery was broad where it branched off the aorta and had a short neck, rendering primary ligation or stump-forming unsuitable. Pathological findings revealed the fragility of the aberrant artery; thus, its root was prone to breakdown of the stump after simple aneurysmectomy. Furthermore, TEVAR may reduce graft infection during lobectomy in the second surgery. The 2-stage surgery may be useful for aberrant aneurysms complicated by pulmonary sequestration.

Retrospective review of the diagnosis and treatment of pulmonary sequestration in 28 patients: surgery or endovascular techniques?

Background

Pulmonary sequestration (PS) is a rare congenital pulmonary malformation. In this study, we aimed to retrospect and evaluate the diagnosis, treatment, and outcomes of PS in 28 patients at our institute.

Methods

The files of 28 patients with PS who were treated with surgery (21 cases) or endovascular intervention (7 cases) between May 2005 and June 2016 from a single institute were retrospectively reviewed. The following data of all patients were analyzed: age, sex, clinical symptoms, diagnostic methods, operative techniques, and treatment outcomes.

Results

Twenty-eight patients, 15 male and 13 female, with a median age of 42.5 underwent operative intervention for PS. Twenty-one patients showed preoperative symptoms including cough, expectoration, hemoptysis, chest and/or back pain, and fever. General chest computed tomography (CT) scanning; percutaneous needle biopsy, bronchoscopy, enhanced CT scanning, and CT angiography (CTA) were used as diagnostic methods. Twenty-one patients were diagnosed preoperatively by enhanced CT scanning and CTA; seven patients were confirmed by surgery. Twenty-one patients underwent surgery (15 cases via thoracotomy and 6 cases via video-assisted thoracic surgery), seven patients underwent interventional therapy (three cases via endovascular embolization and four cases via thoracic aortic endovascular stent-graft exclusion). Three patients had a complication in surgery group (intraoperative hemorrhage in two patients and postoperative hydropneumothorax in one patient) and two patients had post-embolization syndrome in interventional group (fever and pain at embolism site). During the follow-up period ranging from 6 to 84 months, no recurrences or further complications were observed in two groups.

Conclusions

Enhanced CT or CTA may be a potential approach for the diagnosis of PS. Surgical resection for PS is the major treatment approach. Endovascular embolization of PS could be considered when pulmonary lesion is small-sized. Endovascular exclusion could be used to treat combined arterial aneurysm and dissection of PS.